Aim : To establish the appropriate indication of endoscopic treatment for submucosal invasive gastric carcinoma, we reevaluated the risk factors of lymph node (LN) metastasis in 166 cases of differentiated type submucosal invasive gastric carcinoma that had been resected surgically. Results : 29 (17%) of 166 lesions showed histologic heterogeneity. When the submucosal invasive part showed an undifferentiated type, LN metastasis was detected in 6 (21%) of 29 cases. When the submucosal invasive part showed a differentiated type, however, LN metastasis was detected in 18 (13%) of 137 cases. The incidence of LN metastasis of undiffer-entiated type at the submucosal invasive part was higher than that of differentiated type. Well differentiated adenocarcinoma (tub 1) lesion showed no LN metastasis in cases with less than 700pm submucosal invasion. However, moderately differentiated adenocarcinoma lesions (tub2) showed a LN metastasis even in case with minimal submucosal invasion of 300pm. In the result of the multivariate analysis, lymphatic invasion, infiltrative growth pattern (INF)γ and papillary adenocarcinoma (pap) were significant risk factors for LN metastasis. Conclusions : The differentiated type submucosal invasive gastric carcinomas of pap and tub2 at the deepest part showed a higher incidence of LN metastasis. Pap and tub2 lesions should not be included for indications of curative endoscopic mucosal resection (EMR). On the other hand, tubl lesion of INF α without lymphatic invasion showed no LN metastasis. These results indicate that minimal submucosal invasive gastric carcinoma with tubl at the deepest invasive portion and no lymphatic invasion, which shows no other risk factors, can be considered as the appropriate indication for curative EMR.

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In cases of excessed mobility or dislocation caused by diverticulum, tumor or postoperativechange such as Billroth I anastomosis, selective cannulation into comlnon bile duct may be difficult. We describe here a new technique for selective cannulation into tlle cornmon bile ducts in such condition. A guide wire was inserted into the main pallcreatic du.ct in order to control the mobility of the papilla and separate the Qrifice between commoll bile duct and, pancreaticduct. Then the other canllula was inserted into the same working channel side along the guidewire of the duodenoscope. Fixation of the papilla and calmulation of the common bile ductbecorne easier in 200f tota121 cases. No comLplications such as pancreatitis related with thisprocedure were experiellced. We concluded that this new technique is safe and effective for ERCP.

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A63-year-old man was admitted to the hospital because of upper abdominal discomfort.The abdomen was flat and soft, and no tumor was palpated. The gastroscopy and abdominalcomputed tomography revealed a submucosal tu.mor in the gastric antrum Endoscopicultrasonograrn, showed an echogenic mass with some low echoic areas in the third layer of thegastric wal1. Partial gastrectomy was performed, and the mass was resected completely.
The resected mass was 3.0×2.5 cm in size. Microscopically, a few cysts were found withillthe thickening submucosal layer of the antrum. These cysts were lined by gastric type mucosa.Ectopic pancreatic tissue was also found within the thickning submucosal layer of the antrumThe definite diagnosis of du.plication of the stomach with aberrant pancreas was made.
The microscopic findings suggest that the abnoormal deviation of the primitive foregut isone of the cause of gastric duplication.

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Gastrointestinal vascular ectasia is an important cause of gastrointestinal hemorrhage, especially in the aged people and in the patients with cardiovascular disease or chrollic renalfailure. However, careful endoscopic examinations would be necessary for its diagnosis. Wedescribed here two cases of gastrointestinal vascular ectasia successfully treated with endoscopic hemostasis.
Case 1:A40-year-old wornan with chronic heart failure due to mitral regurgitation wasadmitted to our hospital because of general fatigue and severe anemia. Endoscopic examinationrevealed hemorrhagic vascular ectasia at the second portion of duodenum and endoclips wereperformed.
Case 2:A68-year-old man with liver cirrhosis was admitted to our hospital because ofgeneral fatigue. Endoscopic examination revealed hemorrhagic vascu.lar ectasia on the anteriorwall of stomach and ethanol inlection was performed.
In both cases, bleedings were successfully treated by endoscopic hernostasis and no rebleeding has been observed for two years. Endoscopic hemostasis including endoclips and ethanolinjection is a safe and effective treatment for hemorrhagic vascular ectasia.

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Two cases of type AA asymptomatic intestinal amyloidosis were found on the medical examination. A case of them showed not only coarse mucosa but also multiple protruded lesion simulating submucosal tumor which were atypical as type AA and showing similar features to type AL endoscopically, at the 2nd portion of the duodenum. The other case showed fine granular mucosa which was clarified by the contrast method on the greater curvature of the stomach endoscopically. Though they were diagnosed as type AA amyloidosis histologically on the biopsy specimen, they were regarded as primary because they had no basic disease. Furthermore, they were also considered as localized to the upper digestive tract, although deposit of type AA amyloid protein is usually systemic.

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A75-year-old man was admitted to our hospital du.e to massive melena. Althoughcolonoscopic examination perfQrlned on the day of admission could not determine a causativelesion of bleeding because of massive clots of blood, that performed on the following day ofadmission revealed angiodysplasia with a diameter of approximately 10 mm at the rectumbecause no other causative lesions of bleeding wore observed from the terminal ileum to therectum by a careful cololloscopic observation, the diagnosis of rectal bleeding from angiodys-plasia was made. Colonoscopic examination performed on day 6 after admission showed thatthe rectal angiodysplasia became obscure and endoscopic ultrasonography revealed no vascularabnormalities under the angiodysplasia. Fu.rthermore, the rectal angiodysplasia was notobserved any rnore when colonoscopic examination was performed on dad g after admission.Angiodysplasia is one of the most frequently reported causes of lower gastrointestinal bleeding, specifically in the elderly. This is the first report demonstrating the angiodysplasia thatdisappeared spontaneously after massive bleeding. It has been reported that approximately 5%of cases admitted to hospital due to gastrointestinal bleeding were bleeding from sites notdemonstrated by routine diagnostic methods. This report indicates that a considerable numberof cases in which angiodysplasia disappeared spontaneously after bleeding may be irlvolved ingastrointestinal bleeding with unknown causes.

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A 48-year-old man accidentallly swallowed a dental instrument(reamer)at a dental clinic.Although no abdominal symptorns occurred, a plain X-ray film showed that the instrumentremained in the lower right abdomen. Terefore, colonoscQpy was performed at our department18days after the accident. The instrument was stuck in the cecum, where it had caused agranulation-like elevation. It was removed by biopsy forceps holding the tip of the instrument.

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